Provider Demographics
NPI:1437612785
Name:MCNULTY, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 CRAWFORD PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3920
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:106 CARNIE BLVD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4515
Practice Address - Country:US
Practice Address - Phone:856-325-4270
Practice Address - Fax:856-325-4271
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ852043133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered